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LETTERS TO THE EDITORTurk J Hematol 2021;38:228-245Flower-Like Plasma Cell: A CommentÇiçek Benzeri Plazma Hücresi: Bir YorumSmeeta GajendraLaboratory Oncology Unit, Dr. B.R.A. IRCH, AIIMS, New Delhi, IndiaTo the Editor,I read “Flower-Like Plasma Cell Nuclei in Multiple Myeloma”by Sall et al. [1], recently published in this journal. This imagereport is very descriptive and informative regarding a case ofmultiple myeloma showing abnormal plasma cells with flowershapednuclear features. These morphological features can posea diagnostic dilemma and can mimic lymphoma as “flowercells” or clover-leaf lymphocytes are described typically inHTLV-1-induced adult T-cell leukemia and very rarely in B-celllymphoma [2]. Plasma cell myeloma or leukemia rarely presentswith flower‐shaped nuclei and occasional cases of plasma cellleukemia mimicking adult T-cell leukemia/lymphoma werepreviously reported in the literature [3,4]. Upon flowcytometricimmunophenotyping, the absence of B-cell or T-cell markersand the presence of plasma cell markers with strong CD38and CD138 help in differentiating it from lymphoma. Themorphological variation of abnormal plasma cells in plasma cellneoplasms is vast, ranging from small lymphocyte-like cells tocleaved, convoluted, monocytoid or multilobated plasma cellsto anaplastic pleomorphic large plasma cells, which have beenreported previously. A few cases of morphological variants ofplasma cell neoplasms, like megakaryocytic, plasmoblastic, ormegakaryoblastic mimicking acute leukemia, have also beenreported in the literature [5]. The presence of cytoplasmicgranulations, vacuolations, crystals (mimicking histiocytes),Auer rod-like inclusions, or cytoplasmic projections has alsobeen noted in the literature. Morphological transformationof plasma cells into multilobated nuclei during the clinicalcourse followed by anaplastic myeloma transformation isalso occasionally reported [6]. Circulating cells with cleaved,multilobated, or monocytoid nuclei can be present in a varietyof non-hematologic and hematologic disorders, such as reactiveplasmacytosis associated with breast carcinoma, metastaticcarcinoma, plasma cell leukemia, myelomonocytic leukemia,malignant lymphoma, and multiple myeloma [7]. Autoimmunedisorders, hepatitis C, human immunodeficiency virusinfections, angioimmunoblastic T-cell lymphoma, and Hodgkinlymphoma are a few examples in which reactive plasmacytosisof bone marrow may reach levels of up to 30%-50%. Abnormalplasma cells can be differentiated from normal or reactiveplasma cells on flowcytometric immunophenotyping asabnormal plasma cells are mostly CD19-, CD20+, CD27-, CD28+,CD117+, CD56+, CD33+, CD200++, CD307++, CD81-weak to-negative, and clonal for kappa or lambda immunoglobulin[8]. The presence of flower cells in this case demonstratesthe use of immunophenotyping and FISH/cytogenetic studiesin the classification of atypical, multilobated flower-shapedmononuclear cells and also that flower cell morphology is notrestricted only to lymphomas. Sometimes neoplastic plasmacells exhibit cytoplasmic heterogeneity, which poses difficultyin morphological diagnosis and requires ancillary technologylike biopsy with immunohistochemistry or immunophenotypingfor a definitive diagnosis.Keywords: Flower cells, Plasma cell myeloma, Flowcytometricimmunophenotyping, ImmunohistochemistryAnahtar Sözcükler: Çiçek hücreler, Plazma hücre myelom, Akımsitometrik immün fenotipleme, İmmünohistokimyaFinancial Disclosure: The author declared that this studyreceived no financial support.References1. Sall A, Seck M, Samb D, Faye B, Gadji M, Diop S, Touré AO. Flower-likeplasma cell nuclei in multiple myeloma. Turk J Hematol 2021;38:153-154.2. Singh N, Gandhi J, Agrawal N, Panaych A, Tejwani N, Mehta A. Diagnosticdilemma in the morphological detection of flower cells in lymphomas.Indian J Hematol Blood Transfus 2017;33:614-616.3. De Miguel Sánchez C, Robles de Castro D, Pisón Herrero C, Pérez PersonaE, Salcedo Cuesta L, Guinea de Castro JM. Primary plasma cell leukaemiapresenting with flower-shaped nuclei. Br J Haematol 2021;193:689.4. Shibusawa M. Plasma cell leukaemia presenting as flower-shaped plasmacells mimicking adult T-cell leukaemia or lymphoma. Lancet Haematol2020;7:e270.5. Liu K, Song H, Shi J, Zhang W, Mu R, Li L. Rare case of plasma cell myelomawith megakaryoblastic morphology mimicking acute leukemia. Indian JPathol Microbiol 2020;63:485-487.6. Fujimi A, Nagamachi Y, Yamauchi N, Kanisawa Y. Morphologicaltransformation of myeloma cells into multilobated plasma cellnuclei within 7 days in a case of secondary plasma cell leukemiathat finally transformed as anaplastic myeloma. Case Rep Hematol2017;2017:5758368.7. Yeh YA, Pappas AA, Flick JT, Butch AW. A case of aggressive multiplemyeloma with cleaved, multilobated, and monocytoid nuclei, and no serummonoclonal gammopathy. Ann Clin Lab Sci 2000;30:283-288.228
Turk J Hematol 2021;38:228-245LETTERS TO THE EDITOR8. Flores-Montero J, de Tute R, Paiva B, Perez JJ, Böttcher S, Wind H,Sanoja L, Puig N, Lecrevisse Q, Vidriales MB, van Dongen JJ, Orfao A.Immunophenotype of normal vs. myeloma plasma cells: toward antibodypanel specifications for MRD detection in multiple myeloma. Cytometry BClin Cytom 2016;90:61-72.©Copyright 2021 by Turkish Society of HematologyTurkish Journal of Hematology, Published by Galenos Publishing HouseAddress for Correspondence/Yazışma Adresi: Smeeta Gajendra, M.D., Laboratory Oncology Unit, Dr. B.R.A.IRCH, AIIMS, New Delhi, IndiaPhone : 9013590875E-mail : drsmeeta@gmail.com ORCID: orcid.org/0000-0002-1759-7857Received/Geliş tarihi: April 12, 2021Accepted/Kabul tarihi: April 26, 2021DOI: 10.4274/tjh.galenos.2021.2021.0230REPLY FROM THE AUTHORSWe thank Dr. Gajendra for the interest shown in our article.She described in detail the morphological abnormalities, bothnuclear and cytoplasmic, of tumoral plasma cells as well asreactive plasma cells.We fully agree with her that, when in doubt, immunophenotypingis an indispensable tool for distinguishing plasma cells.Unfortunately, we do not have the cytogenetics to deepen thischaracterization.Regards,Abibatou Sall, Moussa Seck, Diama Samb, Blaise Félix Faye,Macoura Gadji, Saliou Diop, Awa Oumar TouréMyeloma and Cystoisospora belliMyelom ve Cystoisospora belliPathum Sookaromdee 1 , Viroj Wiwanitkit 21Private Academic Consultant, Bangkok, Thailand2Honorary Professor, Dr. D.Y. Patil University, Pune, IndiaTo the Editor,We would like to share our ideas on “Prolonged Severe WateryDiarrhea in a Long-Term Myeloma Survivor: An UnforeseenInfection with Cystoisospora belli” regarding multiplemyeloma (MM) patients [1]. Tiryaki et al. [1] concluded that“Parasitic infections are very uncommon… In MM diarrheapoints mainly to infection in acute or chronic form,” furthernoting that, to their best knowledge, “this [was] the firstcase of a patient with MM with C. belli infection” [1]. Theincidence of parasitic infection is usually associated withlocal geography. In developing countries without goodhygienic foundations, parasitic infections are commonbut there is usually no routine screening of MM patients.In a recent report from Brazil, de Castro et al. [2] studiedinfectious diarrhea in autologous stem cell transplantationcases, including myeloma patients, and found that therewere many parasitic infections including C. belli infections. Inconclusion, we suggest a new recommendation for screeningfor parasitic infection in any patients with MM and otherhematological malignancies.Anahtar Sözcükler: Kan, Kanser, Myelom, CystoisosporaAuthorship ContributionsConcept: P.S., V.W.; Design: P.S., V.W.; Data Collection orProcessing: P.S., V.W.; Analysis or Interpretation: P.S., V.W.;Literature Search: P.S., V.W.; Writing: P.S., V.W.Conflict of Interest: No conflict of interest was declared by theauthors.Financial Disclosure: The authors declared that this studyreceived no financial support.References1. Tiryaki TO, Anıl KU, Büyük M, Yıldırım AY, Atasoy A, Örmeci AC, Beşışık SK.Prolonged severe watery diarrhea in a long-term myeloma survivor: anunforeseen infection with Cystoisospora belli. Turk J Hematol 2021;38:171-173.2. de Castro MD, Chebli JM, Costa LJ, Alves KRL, Atalla A, Neto AEH. Infectiousdiarrhea in autologous stem cell transplantation: high prevalence of coccidiain a South American center. Hematol Transfus Cell Ther 2018;40:132-135.Keywords: Blood, Cancer, Myeloma, Cystoisospora229
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